PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (BUERGER'S DISEASE)

Summary

The veteran, who served in the U.S. Army from August 1965 to July 1968, appeals the denial of service connection for several conditions, including bilateral hammer toes, hips, wrists, and lower extremity cold injury residuals. The Board granted secondary service connection for left and right lower extremity peripheral neuropathy, finding it proximately due to the veteran's service-connected diabetes, as previously determined by the AOJ. The Board was bound by this favorable finding. For the denied conditions (hammer toes, hips, wrists, cold injury residuals), the Board considered the veteran's assertions of in-service trauma from parachute jumps, particularly an incident in Alaska. However, the Board found the evidence preponderated against service connection. The May 2024 VA examiner provided a negative nexus opinion, stating that while parachute jumps can cause acute injuries, there was no evidence of late-onset conditions related to them. The examiner also noted the long period between service and symptom onset, the lack of contemporaneous complaints, and the likely etiology of hammer toes and hip arthritis as degenerative wear-and-tear conditions. The Board found this opinion highly probative. The veteran's own statements and treatment records were also considered, with the Board affording more weight to the lack of contemporaneous complaints over later-onset symptom reports. The Board denied service connection for these conditions.

Rationale

AOJ favorable finding in January 2025 rating decision; Board is bound by AOJ's favorable finding; Criteria for secondary service connection met

Full Decision Text

Citation Nr: A26019952
Decision Date: 03/05/26	Archive Date: 03/05/26

DOCKET NO. 240812-463993
DATE: March 5, 2026

ORDER

Entitlement to secondary service connection for left lower extremity (LLE) peripheral neuropathy is granted.

Entitlement to secondary service connection for right lower extremity (RLE) peripheral neuropathy is granted.

Entitlement to service connection for left hammer toe is denied. 

Entitlement to service connection for right hammer toe is denied.

Entitlement to service connection for a left hip disability is denied.

Entitlement to service connection for a right hip disability is denied.	

Entitlement to service connection for a left wrist disability is denied.

Entitlement to service connection for a right wrist disability is denied.	

Entitlement to service connection for LLE cold injury residuals is denied. 

Entitlement to service connection for RLE cold injury residuals is denied.

REMANDED

Entitlement to service connection for a left upper extremity (LUE) neurological disorder is remanded. 

Entitlement to service connection for a right upper extremity (RUE) neurological disorder is remanded. 

Entitlement to service connection for an acquired psychiatric disorder is remanded.  

FINDINGS OF FACT

1. A January 2025 rating decision favorably found that Veteran's LLE and RLE peripheral neuropathy was proximately due to his diabetes. 

2. The Veteran's left and right hammer toes were not incurred during active duty and are not otherwise related to military service.

3. The Veteran's left and right hip disabilities were not incurred during active duty, did not manifest to a compensable degree within one year of separation from service, and are not otherwise related to military service.

4. The Veteran's left and right wrist disabilities were not incurred during active duty and are not otherwise related to military service.

5. The Veteran's LLE and RLE cold injury residuals were not incurred during active duty and are not otherwise related to military service. 

CONCLUSIONS OF LAW

1. The criteria for secondary service connection for LLE peripheral neuropathy are met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for secondary service connection for RLE peripheral neuropathy are met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for service connection for left hammer toe are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for right hammer toe are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

5. The criteria for service connection for a left hip disability are not met.  38?U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 

6. The criteria for service connection for a right hip disability are not met.  38?U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 

7. The criteria for service connection for a left wrist disability are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

8. The criteria for service connection for a right wrist disability are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

9. The criteria for service connection for LLE cold injury residuals are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

10. The criteria for service connection for RLE cold injury residuals are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 1965 to July 1968.  Among his decorations
.102, 3.303.

9. The criteria for service connection for LLE cold injury residuals are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

10. The criteria for service connection for RLE cold injury residuals are not met.  38?U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 1965 to July 1968.  Among his decorations is the Parachutist Badge. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2024 rating decision of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ).  In August 2024, the Veteran submitted a VA Form 10182 and elected the direct review docket and later switched to the hearing docket in September 2024.  He testified before the undersigned Veterans Law Judge in November 2025.  Therefore, the Board may only consider the evidence of record as of June 3, 2024 - the date of the rating decision on appeal and evidence submitted at or within 90 days of the November 24, 2025 hearing.  See 38 C.F.R. § 20.302.  If the Veteran submitted evidence that was added to the record after June 3, 2024 and before the November 24, 2025 hearing or more than 90 days following the hearing, the Board did not consider it.  If the Veteran wishes to have VA consider any evidence that was not considered, a supplemental claim should be submitted identifying such evidence.  See 38 C.F.R. § 3.2501. However, because the Board is remanding the psychiatric and bilateral upper extremity claims, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim.  38 C.F.R. § 3.103(c)(2)(ii).  

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service.  38?U.S.C. §?1110;?38?C.F.R. §?3.303.  Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the current disability and the claimed in-service disease or injury.  Shedden v. Principi,?381 F.3d 1163?(Fed. Cir. 2004).

Certain chronic diseases, including arthritis, will be presumed related to service, absent an intercurrent cause, if shown as chronic in service; or, if manifested to a compensable degree within a presumptive period following separation from service; or, if noted in service (or within an applicable presumptive period) with continuity of symptomatology since service.  38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309.  Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. §?3.310(a).  Secondary service connection generally requires evidence showing (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability.  Wallin?v. West, 11?Vet. App.?509 (1998).

1. Entitlement to secondary service connection for LLE peripheral neuropathy is granted.

2. Entitlement to secondary service connection for RLE peripheral neuropathy is granted.

Any finding favorable to the claimant made by either a VA adjudicator or by the Board is binding on all subsequent AOJ and Board adjudicators, unless rebutted by evidence that establishes a clear and unmistakable error in the favorable finding.  A finding means a conclusion either on a question of fact or on an application of law to facts made by an adjudicator concerning the issue(s) under review.  See 38?C.F.R. §?3.104(c).

In a January 2025 rating decision, the AOJ determined that the Veteran's LLE and RLE peripheral neuropathy was secondary to his service-connected diabetes and
 is granted.

2. Entitlement to secondary service connection for RLE peripheral neuropathy is granted.

Any finding favorable to the claimant made by either a VA adjudicator or by the Board is binding on all subsequent AOJ and Board adjudicators, unless rebutted by evidence that establishes a clear and unmistakable error in the favorable finding.  A finding means a conclusion either on a question of fact or on an application of law to facts made by an adjudicator concerning the issue(s) under review.  See 38?C.F.R. §?3.104(c).

In a January 2025 rating decision, the AOJ determined that the Veteran's LLE and RLE peripheral neuropathy was secondary to his service-connected diabetes and awarded service connection for LLE and RLE peripheral neuropathy of the sciatic and femoral nerves and assigned an initial 20 percent rating for each condition.  As the Board is bound by these favorable findings, the criteria for entitlement service connection for LLE and RLE peripheral neuropathy are met.  While this decision was generated after the June 2024 rating decision on appeal, a decision by a VA adjudicator or by the Board is not "evidence" and is binding on the Board.  Accordingly, secondary service connection for LLE and RLE peripheral neuropathy is granted.

3. Entitlement to service connection for left hammer toe is denied. 

4. Entitlement to service connection for right hammer toe is denied.

5. Entitlement to service connection for a left hip disability is denied.

6. Entitlement to service connection for a right hip disability is denied.

7. Entitlement to service connection for a left wrist disability is denied.

8. Entitlement to service connection for a right wrist disability is denied.	

9. Entitlement to service connection for LLE cold injury residuals is denied. 

10. Entitlement to service connection for RLE cold injury residuals is denied.

The Veteran is currently diagnosed with bilateral hammer toe and bilateral hip degenerative arthritis.  See February 2024 VA examination reports.  Although the February 2024 VA examiner did not diagnose the Veteran with a bilateral wrist disability or lower extremity cold injury residuals, the Board notes pain that results in functional impairment of earning capacity may constitute a disability for VA purposes.  See Saunders?v. Wilkie, 886 F.3d 1356?(Fed. Cir. 2018).  Affording him the benefit of the doubt, the first element of service connection is established for all disabilities. 

Turning to the second element, in-service incurrence of a disease or injury, the Veteran's service treatment records (STRs) are negative for any complaints, symptoms, treatment for, or diagnosis of a toe, hip, wrist, or lower cold injury condition.  However, the Veteran asserts that his disabilities are the result of in-service parachute jumps and states that he jumped close to 40 times.  He reported an particular incident while stationed in Alaska when he jumped wearing a rucksack containing a month's worth of clothes, a M60 machine gun with 500 rounds of ammunition, and two telephones with 500 yards of wire, but instead hit the side of the plane and ended up stuck in the snow when he hit the ground and unable to move for about 45 minutes in extreme cold weather until someone came to get him.  The Veteran's individual jump record, DA Form 1307, shows that he completed 23 jumps during service; 5 in Georgina during airborne school and 18 in Alaska, most of which were performed with combat equipment.  The Board finds the Veteran's report of a jump injury in Alaska is consistent with the circumstances of his service.  38 U.S.C. § 1154(a).  Thus, element two is also met.

As for the final element, nexus, the only competent opinions of record are against the claims.  Specifically, the May 2024 VA examiner opined that the Veteran's bilateral hammer toe, hip, and wrist disabilities and lower extremity cold injury residuals were less likely than not incurred in or caused by service.  In support, the examiner noted that injuries following parachute jumps had been intensively studied (>200,000 jumps) and indicated that lower extremity injuries made up 65 percent of total injuries, followed by 22 percent head injuries, 22 percent neck or back injuries, and 19 percent upper extremity injuries.  She explained the data supported acute injuries associated with parachute jumps but that there was no evidence of late onset conditions associated with parachute jumps, and highlighted the absence of any toe, hip, wrist, or lower extremity cold residual complaints for more than three decades after separation from service.  She further indicated that the most common cause of hammer toes was wearing short narrow shoes that were too tight, as it forced the toe into a bent position and caused muscles and tendons in the toe
 parachute jumps had been intensively studied (>200,000 jumps) and indicated that lower extremity injuries made up 65 percent of total injuries, followed by 22 percent head injuries, 22 percent neck or back injuries, and 19 percent upper extremity injuries.  She explained the data supported acute injuries associated with parachute jumps but that there was no evidence of late onset conditions associated with parachute jumps, and highlighted the absence of any toe, hip, wrist, or lower extremity cold residual complaints for more than three decades after separation from service.  She further indicated that the most common cause of hammer toes was wearing short narrow shoes that were too tight, as it forced the toe into a bent position and caused muscles and tendons in the toe to tighten and become shorter.  She explained that osteoarthritis was the most common form of arthritis, which affected millions of people worldwide, and occurred when the protective cartilage that cushions the ends of the bones wore down over time and that degenerative (osteoarthritis) arthritis symptoms often developed slowly and worsened over time, noting it was a wear and tear disease and the likely etiology of the Veteran's hip disability.  While the examiner noted that there could be long term effects with severe frostbite, she emphasized the almost four decades between lower cold residual symptoms and service.  This opinion is highly probative, as the examiner considered the Veteran's pertinent medical history and provided a cogent rationale supported by the record. 

While an August 2015 VA treatment record indicates that the Veteran's foot pain was a "possible long term effect from frostbite," this statement is afforded no probative value for use of speculative language.  Moreover, the Veteran did not report that he received or sought medical treatment for his feet after the snow incident and that only his hands were treated, which suggests that his feet were not severely frostbitten so as to result in long term effects and further bolsters the May 2024 VA opinion, as does the July 2015 VA treatment record (podiatrist noting that the Veteran was wearing a size 9.5 shoe but his feet measured to a size 11.5 - close to a size 12 medium shoe, and that purchasing larger shoes would likely resolve his foot pain, including his hammer toe deformity).  VA treatment records reflect that the Veteran consistently reported a history of frostbite specifically to his hands yet did not mention his feet had also been frostbitten until August 2015.  See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present).  

Additionally, in seeking treatment at VA, the records show that the Veteran did not indicate that his toe, hip, wrist, and lower cold injury conditions began in service nor did he endorse continuous symptoms since service at any point and instead noted the more recent onset of symptoms.  See e.g., May 2009 (reporting right wrist swelling for one week); September 2011 (reporting left hip pain starting a few days ago with no trauma); May 2014 (reporting toe pain for 4 days); and August 2021 (reporting right hip pain for 2 weeks) VA treatment records.  As such, although the May 2024 examiner emphasized the length of time before the Veteran sought treatment after service, this does not render the opinion inadequate and the Board affords more probative value to the lack of any indication of any toe, hip, wrist, and lower cold injury complaints in the record for decades after service than the Veteran's more recent statements in conjunction with his claim for benefits.  Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (when a medical condition or symptom has not been noted in the medical records, the Board may not consider that as negative evidence unless it is the sort of condition or symptom that would normally be noted or reported); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that evidence of a prolonged period without medical complaint can be considered, along wither other factors concerning the veteran's health and medical treatment during and after military service).  

To the extent that the Veteran asserts that his bilateral hammer toe, hip, wrist, and lower cold injury disabilities are the result of service, the Board finds that he is not competent to do so, as the determination as to the etiology of such conditions is a medically complex question that is beyond the ken of a layperson.  See Jandreau v. Nicholson, 492 F.3d 1372 (
); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that evidence of a prolonged period without medical complaint can be considered, along wither other factors concerning the veteran's health and medical treatment during and after military service).  

To the extent that the Veteran asserts that his bilateral hammer toe, hip, wrist, and lower cold injury disabilities are the result of service, the Board finds that he is not competent to do so, as the determination as to the etiology of such conditions is a medically complex question that is beyond the ken of a layperson.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  Furthermore, because there is no evidence that his bilateral hip arthritis manifested to a compensable degree within a year of service, presumptive service connection for a chronic disease is not established.  Nor is there any competent and credible evidence of an in-service manifestation of arthritis in either hip to allow for service connection based on continuity of symptomatology; in any event, as noted above, the Veteran indicated an onset of these conditions in more contemporaneous treatment records no earlier than 2009, decades after service.  38 C.F.R. § 3.303(b).  Although the Veteran participated in a toxic exposure risk activity (TERA), an exception to the TERA opinion requirement applies since he indicates that his disabilities are due to physical trauma.  See 38 U.S.C. § 1168(b); VBA Letter 20-24-06, Updated Guidance on Processing Claims Involving the PACT Act, 89 Fed. Reg. 51, 224 (Jun. 17, 2024). 

Accordingly, as the competing evidence is not in approximate balance, or nearly equal, the benefit-of-the-doubt rule is inapplicable, and service connection must be denied.  See?38?U.S.C. §?5107(b); Lynch v. McDonough,?21 F.4th 776 (Fed. Cir. 2021); 38?C.F.R. §?3.102.? 

REASONS FOR REMAND

11. Entitlement to service connection for a LUE neurological disorder is remanded. 

12. Entitlement to service connection for a RUE neurological disorder is remanded. 

The January 2017 and February 2024 VA examiners found no evidence of an upper extremity neurological condition.  However, a December 2022 VA treatment record reflects negative sensation and decreased reflexes in the Veteran's upper extremities, though the record does not indicate a diagnosed disorder.  Notably, the Veteran is service-connected for bilateral hand cold injury residuals under diagnostic code (DC) 7122.  It is unclear whether his upper extremity symptoms are manifestations of his cold injury residuals or if they are attributable to a separate neurological condition.  The failure to seek clarification is a pre-decisional duty to assist error requiring a new VA examination on remand.

13. Entitlement to service connection for an acquired psychiatric disorder is remanded.  

The Veteran has not been afforded a VA examination for his acquired psychiatric disorder the duty to obtain one is triggered based on the pre-decisional evidence of record, given the Veteran's current diagnoses and his reports of an traumatic jump incident at the October 2022 Board hearing.  McLendon v. Nicholson, 20 Vet. App. 79 (2006).  This is a pre-decisional duty to assist error requiring a remand.

The matters are REMANDED for the following action:

Schedule the Veteran for a VA examination to determine the nature and etiology of his bilateral upper neurological disorder and acquired psychiatric disorder.  The claims file should be made available to the examiner.  All indicated tests should be conducted and all findings reported in detail.  After a review of the claims file, the examiner is asked to address the following:

(a)	Indicate whether the Veteran has had a diagnosis of an upper extremity neurological disorder at any point since September 2016, even if currently resolved, that is separate and distinct from his service-connected bilateral hand cold injury residuals. 

If no upper extremity neurological disorder is diagnosed, please address whether the abnormal neurological findings (see December 2022 VA treatment record) and the Veteran's reports of functional impairment are manifestations or symptoms of his service-connected bilateral hand cold injury residuals rated under DC 7122. 

(b)	For any diagnosed upper extremity neurological disorder or associated functional impairment that is separate and distinct from the cold injury residuals, is it at least as likely as not (approximately 50 percent probability or nearly 50 percent probability) that such condition:

(1)	was caused by his service-connected bilateral hand cold injury residuals and/or diabetes
 2016, even if currently resolved, that is separate and distinct from his service-connected bilateral hand cold injury residuals. 

If no upper extremity neurological disorder is diagnosed, please address whether the abnormal neurological findings (see December 2022 VA treatment record) and the Veteran's reports of functional impairment are manifestations or symptoms of his service-connected bilateral hand cold injury residuals rated under DC 7122. 

(b)	For any diagnosed upper extremity neurological disorder or associated functional impairment that is separate and distinct from the cold injury residuals, is it at least as likely as not (approximately 50 percent probability or nearly 50 percent probability) that such condition:

(1)	was caused by his service-connected bilateral hand cold injury residuals and/or diabetes;

(2)	got worse from his service-connected bilateral hand cold injury residuals and/or diabetes; or 

(3)	had its onset in or is otherwise related to service, to include as a result of his TERAs therein?

In addressing this question, the examiner must consider (i) the total potential exposure through all applicable deployments; and (ii) the synergistic, combined effect of all TERAs of the Veteran.

(c)	Identify all diagnosed DSM-5 psychiatric disorders present since September 2016, even if currently resolved, to include unspecified anxiety disorder and unspecified reaction to severe stress.  If any of the diagnoses are not warranted, please reconcile these findings with the diagnoses of the same in the July and October 2020 VA treatment records. 

(d)	For each psychiatric disorder so diagnosed, is it at least as likely as not (approximately 50 percent probability or nearly 50 percent probability) that such disorder:

(1)	had its onset in or is otherwise related to service, to include as a result of the Veteran's reported traumatic parachuting incident in Alaska; 

(2)	was caused by his service-connected bilateral hand cold injury residuals; or 

(3)	got worse from his service-connected bilateral hand cold injury residuals?

(e)	If a diagnosis of posttraumatic stress disorder is warranted, specify the stressor(s) upon which that diagnosis is based.

A complete rationale should be provided for all opinions, citing to specific evidence of record and medical principles, as necessary.  If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).

If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency.  If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional with the knowledge and training needed to render such an opinion.

 

 

S. BUSH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. S. Mahoney

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.